- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $977.24 / $1,584.89
| Professional | | $851.14 | $977.24 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218,776.16 / $524,807.46 / $954,992.59
| Facility | | $218,776.16 | $524,807.46 | $954,992.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,344.23
| Professional | | $1,778.28 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,659.59
| Facility | | $1,318.26 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $954.99 / $1,318.26
| Professional | | $776.25 | $954.99 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,089.30 / $2,454.71
| Facility | | $1,000.00 | $2,089.30 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $1,412.54
| Professional | | $602.56 | $977.24 | $1,412.54 |